Labor Challenge

Breech Position

The most common position for a baby to be in during labor is called the vertex, or head down position. A breech baby is not head down, but rather feet or buttocks down. There are three different breech positions a baby can be in:

  • Frank Breech - buttocks are down and legs go straight up.
  • Complete Breech - baby is sitting cross-legged.
  • Footling Breech - either one or two feet down.
  • In any breech position, the baby will exit the uterus feet or buttocks first, the head being the last part to be born. Approximately 15 % of babies are breech at 29-32 weeks, 7% of babies are breech at 38 weeks of pregnancy, only 3-4% are breech at 40 weeks pregnancy.

    Why is a breech position a labor challenge?

    Babies who are in a breech position fare worse than babies who are in a head down (called vertex) position regardless of the way they are born. This is due to many factors not necessarily related to the babies position. First, babies who are born prematurely are more likely to be breech than their full term friends because they have not had the opportunity to move into a head down position yet. Breech position is also more common in babies with neuro-muscular problems because they do not have the coordinated movements to move to a head down position. Breech babies with either of those issues will have problems whether born by cesarean surgery or vaginally.

    Childhood handicap is more common among breech babies whether the baby is born vaginally or through a cesarean surgery. This means it is not the breech birth that causes the problem, but may be a problem the baby was already dealing with which caused the breech. Because of this, experts are beginning to see the head down position as a baby's first developmental milestone. However, it is also possible for a baby to be stuck in a breech position because of issues with the mother's pelvis.

    Whether it is safer for a breech baby to be born vaginally or by cesarean is still under debate. There is currently a study underway which may help unmuddy the waters, but until that happens, concerns about the possible complications from a breech vaginal birth make it almost impossible to find a care provider willing to catch a breech baby. But having risks in a vaginal birth does not erase the risks of cesarean birth, which are also higher for breech babies than for vertex babies.

    During a vaginal birth, having the head come out last increases the risk that the umbilical cord will be compressed or prolapsed. A compressed cord is not able to provide oxygen to the baby. Additionally, because the head is coming out neck first, it is less likely to mold increasing the risk for the head to get stuck. If the baby is in the frank or complete breech positions and the body passes through without a problem, the head generally follows without problem. Still, the death rate for breech babies is 4 times higher than for head first or vertex presentation babies. Thankfully, in developed countries, death rates for babies are very low.

    Because of the increased risk, many doctors and midwives have stopped attending vaginal breech births. Instead, the standard treatment is to schedule a cesarean section at the earliest possible date. As fewer doctors and midwives participate in vaginal breech births, the skills necessary to safely attend the mother are lost. The main skill when working with a breech birth is to keep your hands off (i.e. don't pull on the baby). The baby must be delivered by the mother's pushing because pulling on the body can cause trauma to the head and neck. This is the most common cause of trauma to a breech baby during a cesarean surgery but is unavoidable when surgery is performed.

    There are many techniques that can be used to assist a vaginal breech birth. Positions such as hands and knees or at least squatting help to avoid the baby being stuck. There are also techniques to release arms or legs that do not release on their own. How much experience your midwife has with breech birth depends on many factors, so the only way to know is to ask her.

    In breech births the buttocks present first With breech birth, the head presents last
    In breech birth, the head is the last part of the baby to be born.

    Potential Solutions

    Try techniques to turn the baby before labor begins. If the baby will not turn, find a caregiver who is experienced in assisting at a breech labor.

    Things to discuss with your caregiver:

    As you near the end of your pregnancy, you may want to discuss ways to encourage your baby to move into a head down position. Some women have success with chiropractors familiar with techniques for encouraging proper positioning. Other women spend time with their hips higher than their head by either lying upside down on an inclined ironing board or by placing pillows under their hips. If your doctor feels your health is good, you may want to try one or both of these techniques. Learn how to determine your baby's position for yourself.

    Some women try placing a flashlight or headphones near their pubic bone, in an attempt to encourage the baby to move head down. Some experts recommend talking to the baby and telling him it is time to turn. Although no studies support the success of either of these methods, they seem to be harmless and your caregiver may encourage you to try them.

    A medical method for turning the baby is called an external cephalic version. In this procedure, you will be given a medication that relaxes the uterus (tocolytic) and some doctors also use an epidural to minimize discomfort. Your caregiver will push and press your baby into a head down position. A Cochrane Review of the studies of external version has found that use of the tocolytic improves the success of turning the baby. This procedure is easiest to perform earlier in the pregnancy, but a large number of babies return to the breech position when it is done early and the risks to baby are higher before 37 weeks gestation. Waiting until at least 37 weeks to attempt a version gives your baby time to turn on his own and makes the version safer because if any complications occur the baby can be born immediately.

    external version external version
    An external version is an attempt to make the baby turn.

    A Cochrane Review of the literature found that cesarean section did decrease the rate of death for breech infants. However, it did cause an increase in problems for the mother after the baby was born. If you know that your only option will be a cesarean (either because of lack of professionals who can attend a vaginal breech or because of other concerns for health), you may be able to delay the surgery until early labor begins. This would give your baby every opportunity to turn into the head down position.

    Breech Birth is definitely a challenge for which it pays to shop around. Different caregivers have different skills and experiences, so will treat the breech birth according to what they feel is safe. If your caregiver does not feel comfortable with the way you want to handle things, interview others. You may find a caregiver familiar with the techniques you want to try. Some questions to ask:

  • Is there any problem with my trying alternative methods for turning my baby (such as moxibustion, pelvic adjustment with a chiropractor, hypnosis or positioning to turn the baby)?

  • When do you consider it time to try an external cephalic version? (Note: research indicates that early ECV is more successful)

  • Under what circumstances will you recommend a cesarean surgery?

  • Will I be disqualified from attempting a vaginal breech if this is my first baby?

  • References:
    Goer, Henci. The Thinking Woman's Guide to a Better Birth. 1999. New York: The Berkley Publishing Group.
    Enkin, Keirse, Nilson, Crowther, Duley, Hodnett and Hofmeyr. A guide to effective care in pregnancy and childbirth Third Edition. 2000. Oxford: Oxford University Press.
    Hofmeyr GJ. Interventions to help external cephalic version for breech presentation at term (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd.
    Hofmeyr GJ, Hannah ME. Planned caesarean section for term breech delivery (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd.